Escolar Documentos
Profissional Documentos
Cultura Documentos
Sam D. Shemie, Heather Ross, Joe Pagliarello, Andrew J. Baker, Paul D. Greig, Tracy Brand, Sandra
Cockfield, Shaf Keshavjee, Peter Nickerson, Vivek Rao, Cameron Guest, Kimberly Young,
Christopher Doig; on behalf of the Pediatric Recommendations Group
• Bronchoscopy can be performed by the local hospital ex- Recommendation 10.3: Indications for liver biopsy
pert and reported to the responsible transplant surgeon.
• Antimicrobial therapy should be based on the results of We recommend the following indications for ultrasound-
Gram staining or culture or suspected or confirmed bron- guided percutaneous liver biopsy in the ICU before procure-
chopneumonia. ment, in consultation with the liver transplant team, to enable
• Empiric broad-spectrum antibiotics are not routinely indi- decisions about transplantability:
cated, but may be used in donors at high risk of bronchop- • Weight > 100 kg or body mass index > 30 or HCVAb posi-
neumonia. tive donor and
• Length of stay in the ICU is not an independent indication • Distant procurement, i.e., when a procurement team is not
for antimicrobial therapy. immediately available.
Intraoperative biopsy by the liver retrieval team is rec-
Key considerations ommended in all other instances where liver biopsy is
• Technology should be developed to enable: indicated.
- remote review of bronchoscopy and chest radiographic If the biopsy cannot be done in the ICU and indications for
images biopsy exist, the liver should be offered and transplantation
- 3-way communication among ICUs, organ procure- should be at the discretion of the liver transplant team.
ment organizations and transplant surgeons
• Nephrotoxic antimicrobials should be avoided when Key considerations
possible. None.
The following was identified as an area of well-accepted prac- The following were identified as areas of well-accepted prac-
tice and endorsed a priori: tice and endorsed a priori:
• Potential liver donors are assessed for • A normal creatinine clearance rate (> 80 mL/minute/
- history of jaundice, hepatitis, excessive alcohol in- 1.73 m2) defines the optimum function threshold for
gestion transplantation. However, an abnormal serum creatinine
- hepatic aspartate aminotransferase (AST), alanine level or calculated creatinine clearance rate in a donor does
aminotransferase (ALT), bilirubin (direct and indirect not necessarily preclude use of the donor kidneys.
where available) and international normalized ratio • Urinalysis is essential to rule out kidney abnormalities.
(INR) or prothrombin time (PT), repeated every 6 h • Creatinine and serum urea (blood urea nitrogen) are meas-
- serum electrolytes, creatinine, urea hepatitis B surface ured every 6 h.
antigen (HBsAg),
hepatitis B core antibody (HBcAb), hepatitis C virus antibody Recommendation 11.1: Creatinine clearance rate
(HCVAb).
We recommend that measurement of creatinine clearance
Recommendation 10.1: Upper limits of hepatic rate be based on the Cockroft–Gault equation; urine collec-
aspartate aminotransferase (AST) and alanine tion to measure creatinine clearance is not indicated.
aminotransferase (ALT)
Key consideration
We recommend that there be no upper limits for hepatic AST There is no absolute contraindication to kidney donation
and ALT that preclude liver transplantability. All livers based on a serum creatinine level or creatinine clearance rate
should be offered; decisions related to transplantability de- alone.
pend on organ status, trends in liver function over time and
recipient status. Recommendation 11.2: Renal ultrasound
Key considerations
12. Optimum time for organ procurement and deci- • Accountability for nonutilization of organs is required
sions regarding transplantability from procurement and transplant services. The limited
data currently provided to the Canadian Organ Replace-
Recommendation 12.1: Optimum time for organ ment Register recording reasons for nonutilization of or-
procurement gans are inadequate.
• Utilization of organs should be linked with corresponding
It is important to take the necessary time in the ICU to opti- transplant graft and patient outcomes.
mize multi-organ function to improve transplant outcomes. • Issues related to transmissible viruses or malignancy should
Reversible organ dysfunction can be improved with resuscita- comply with existing Canadian standards and guidelines.16
tion and re-evaluation. The treatment period can range from
12 to 24 h and should be accompanied by frequent re-evalua- 13. Pediatric age-related adjustments
tion to demonstrate improvement in organ function toward
defined targets. Once organ function is optimized, surgical Recommendation 13: Pediatric age-related
procurement procedures should be arranged emergently. adjustments
Existing Canadian practice We recommend that Recommendations 1–12 be applied to in-
fants, children and adolescents with the following qualifica-
In general, after neurological death has been declared and tions. (The numbers are those of the corresponding adult rec-
consent to organ donation has been given, efforts are made to ommendations.)
complete donation logistics and initiate procurement as
quickly as possible. Overarching
• Central venous oximetry is currently used in many Cana- • Serial echocardiography is recommended to evaluate myo-
dian pediatric ICUs as a monitoring technique in patients cardial function for the purposes of transplantation. The
with hemodynamic instability and is recommended for the initial echocardiogram should be performed only after sta-
pediatric donor. Therapy should be titrated to a central ve- bilization with adequate volume resuscitation.
nous oxygen saturation of ≥ 60%. • The echocardiogram should be repeated every 6–12 h un-
der the following conditions:
2.3:Indications for PAC - initial 2 dimensional echocardiogram reveals an ejec-
tion fraction ≤ 40% or
• The use of PAC is limited in pediatric ICU practice and is - escalation of supports as defined by dopamine
not routinely recommended in pediatric donors. PAC may > 10µg/kg per minute, the use of vasopressor agents or
be used at the discretion of the pediatric ICU practitioner both.
who is experienced with its application and interpretation.
• Serial echocardiography is the recommended method for 11.1: Creatinine clearance rate
re-evaluating myocardial function for transplantation. Its
role as a potential tool to guide hemodynamic therapy • For children > 1 year of age, a normal creatinine clearance
should be individually tailored. rate is > 80 mL/minute/1.73 m2 , as estimated by the
Schwartz formula.18
2.4:First-line agents for hemodynamic support —
vasopressin 11.3:Indications for kidney biopsy
• The pediatric dose range for vasopressin is 0.0003– • Creatinine level higher than normal for age.
0.0007 U/kg per minute (0.3–0.7 mU/kg minute) to a max-
imum dose of 2.4 U/h. Key considerations
See Table 1.
2.5:Second-line agents for hemodynamic support —
Norepinephrine, epinephrine and phenylephrine
Table 1: Age-related norms for heart rate and blood pressure
• In the absence of PAC data, hemodynamic therapy Age Heart Rate Systolic BP Diastolic BP
should be titrated to clinical and biochemical targets. beats/min (mm Hg) (mm Hg)
• The pediatric dose range for vasopressin is 0.0003– 6–12 mo 80–120 80–100 55–65
0.0007 U/kg per minute (0.3–0.7 mU/kg per minute) to a 1–3 yr 70–110 90–105 55–70
maximum dose of 2.4 U/h. 3-6 yr 65–110 95–110 60-75
Adapted from: Mathers LH, Frankel LR. Stabilization of the Critically Ill Child.
• The pediatric dose range for vasopressin is 0.0003– Nelson textbook of pediatrics, 17th Edition, 2004.19
REFERENCES
1. Hornby K, Shemie SD. Donor organ management: survey of guidelines and eligibil-
ity criteria. Edmonton: Canadian Council for Donation and Transplantation; 2004.
2. Hornby K, Ross H, Keshavjee S, et al. Factors contributing to non-utilization of Correspondence to: Dr. Sam D. Shemie, Division of Pediatric
heart and lungs after consent for donation: a Canadian multicentre study. Can J Critical Care, Montreal Children’s Hospital, McGill University
Anaesth 2006; in press.
3. Tung P, Kopelnik A, Banki N, et al. Predictors of neurocardiogenic injury after sub- Health Centre, Montréal, QC H3H 1P3;
arachnoid hemorrhage. Stroke 2004; 35(2):548-51. sam.shemie@muhc.mcgill.ca
4. Novitzky D. Detrimental effects of brain death on the potential organ donor.
Transplant Proc 1997;29:3770-2. Reprint requests to: Ms. Kimberly Young, Canadian Council for
5. Shivalkar B, Van Loon J, Wieland W, et al. Variable effects of explosive or gradual
increase of intracranial pressure on myocardial structure and function. Circulation Donation and Transplantation, 1702–8215 112 Street, Edmonton
1993;87(1):230-9. AB T6G 2C8; 780 409-5652; kimberly.young@ccdt.ca
Forum participants concluded that there are significant limitations to existing clinical research in support of forum recommendations.
Participants encouraged the development of local and multi-centre research initiatives, as well as those at national and international
levels. The following potential research topics were collected during small-group discussions.
Topics amenable to survey methods
• A cross-sectional survey examining current practice in the cardiopulmonary support of donors, including hemodynamic targets and
supports, ventilation and lung recruitment strategies.
Topics amenable to observational studies
The following questions include survey methods, prospective and retrospective studies and database reviews:
• Contribution of serial echocardiography or dobutamine stress echocardiography to the evaluation of patients with reduced myocardial
function compared with PAC alone
• Effect of radiographic contrast exposure (during cerebral angiography or coronary angiography) on renal graft function
• Investigation of the factors that contribute to variability of organ utilization rates between centres and correlation to post-transplant
function
• Optimum vasopressor and inotrope combinations and the influence of delayed procurement on organ utilization
Topics amenable to non-randomized intervention studies
• Effect of serial lung recruitment maneuvers in organ donors on the PaO2/FiO2 ratio and lung procurement rates
• Pharmacologic studies of orally and intravenously administered T4 and T3 in humans, including kinetics, biological effects, optimum
dosing, peripheral conversion times and effect of corticosteroids
Topics amenable to simple randomized controlled clinical trials
• Does combined hormonal therapy improve hemodynamics, organ function or organ utilization?
• Do PAC and goal-directed therapy improve hemodynamics, organ function or organ utilization?
• Evaluating the use of prophylactic N-acetylcysteine to prevent constrast nephropathy and delayed graft function of deceased donor
kidneys
Optimizing donor management and organ utilization for transplantation requires widespread communication of the recommendations of
this forum combined with broad engagement of individuals and organizations across the health system. To address these interdependent
requirements, a Logistics and Knowledge Transfer (LKT) Group (see Appendix 4) met throughout the forum to address the question:
How can we ensure that the agreements developed at this forum are transferred into the field efficiently and
effectively so that improvements in medical management occur as soon as possible?
Members of the LKT group developed recommendations to address both logistic and knowledge transfer challenges in relation to clinical
practice and systemic change.
Logistics challenges
The LKT group discussed ways to facilitate the implementation of the guidelines (e.g., a standardized set of guidelines would promote
clinical excellence and lead to the creation of constructive hospital policies) and factors that would hinder their implementation (e.g.,
consideration of resource implications for extended stays in the ICU, reduced organ recovery options due to lack of access to operating
room time and a lack of a definition of what constitutes an organ procurement hospital). They made the following recommendations to
address the logistic issues that might hinder implementation of the guidelines:
• Prepare a cost–benefit analysis of donation, including implications for the health care system and quality-of-life issues.
• Monitor and report on the resolution of logistic challenges on an individual case basis with respect to their impact on optimum organ
utilization.
Knowledge transfer challenges
The Canadian Institutes of Health Research (CIHR) describe knowledge transfer as the process that transfers research results from
knowledge producers to knowledge users for the benefit of Canadians.20 It comprises three interlinked components:
• Knowledge exchange
• Knowledge synthesis
• Ethically sound application of knowledge.
The goal of knowledge transfer is to improve health processes, services and products as well as the health care system itself.
Members of the LKT group made the following recommendations (alphabetical order) to maximize knowledge transfer and enhance
organ utilization:
• Develop policies to guide the donation process that clearly identify roles and responsibilities for health care professionals (e.g.,
incorporation of the recommendations of this forum into standard operating procedures at organ procurement organizations and
hospitals).
• Encourage national and international exchange of information to advance knowledge and care within and beyond Canada.
• Ensure that allocation issues do not complicate utilization, resulting in unused organs.
• Include the identification of potential organ and tissue donors as part of high-quality end-of-life care to maximize organ utilization.
• Provide health care professionals with ongoing education and skill development in support of high-quality care for donors and their
families. Develop quick reference tools for protocols and guidelines.
• Support the implementation of the forum’s recommendations in organizations and institutions affiliated with the forum.
• Support initiatives to enhance reporting and accountability. Encourage standardization of data and terminology both nationally and
internationally. Develop high-quality measurements that reflect directly on the donation process, including identification of donors,
requests for consent, giving consent and utilization of organs.
It is important to take the necessary time in the ICU to optimize multi-organ function to improve transplant outcomes. Resuscitation and
re-evaluation can improve reversible organ dysfunction (myocardial and cardiovascular dysfunction, oxygenation impairment related to
potentially reversible lung injury, invasive bacterial infections, hypernatremia) and evaluate temporal trends in hepatic aspartate
aminotransferase (AST), alanine aminotransferase (ALT) and creatinine or any other potentially treatable situation. This treatment period
can range from 12 to 24 h and should be accompanied by frequent re-evaluation to demonstrate improvement in organ function toward
defined targets. Once organ function is optimized, surgical procurement procedures should be arranged emergently.
There are no demographic factors or organ dysfunction thresholds that preclude giving consent for donation and offering organs for
transplantation.
Adult donors
Standard • Urine catheter to straight drainage, strict intake and output
monitoring • Nasogastric tube to straight drainage
• Vital signs every hour
• Pulse oximetry, 3-lead ECG
• Central venous pressure
• Arterial line pressure
• Optional PAC
Laboratory • Arterial blood gases, electrolytes and glucose every 4 h and as needed
investigations • Complete blood count every 8 h
• Blood urea nitrogen and creatinine every 6 h
• Urine analysis
• AST, ALT, bilirubin (total and direct), INR (or PT) and PTT every 6 h
Hemodynamic General targets: heart rate 60–120 bpm, systolic blood pressure > 100 mm Hg, mean arterial pressure ≥ 70 mm Hg
monitoring • Fluid resuscitation to maintain normovolemia, central venous pressure 6–10 mm Hg
and therapy • If arterial blood pressure ≥ 160/90 mm Hg, then: Wean inotropes and vasopressors and, if necessary, start
- Nitroprusside: 0.5–5.0 µg/kg per minute or
- Esmolol: 100–500 µg/kg bolus followed by 100–300 µg/kg per minute
• Serum lactate every 2–4 h
• Mixed venous oximetry every 2–4 h; titrate therapy to MVO2 ≥ 60%
Agents for • Dopamine: ≤ 10 µg/kg per minute
hemodynamic • Vasopressin: ≤ 2.4 U/h (0.04 U/minute)
support • Norepinephrine, epinephrine, phenylephrine (caution with doses > 0.2 µg/kg/minute)
Indications for • 2-dimensional echo ejection fraction ≤ 40% and/or
PAC • Dopamine >10 µg/kg per minute (or equivalent) and/or
• Vasopressor support (not including vasopressin if part of hormone therapy) and/or
• Escalation of supports
Glycemia and • Routine intravenous dextrose infusions
nutrition • Initiate or continue enteral feeding as tolerated
• Continue parenteral nutrition if already initiated
• Initiate and titrate insulin infusion to maintain serum glucose level at 4–8 mmol/L
Fluid and • Urine output 0.5–3 mL/kg per h
electrolyte • Serum Na 130–150 mM
targets • Normal ranges for potassium, calcium, magnesium, phosphate
Diabetes Defined as:
insipidus • Urine ouptut > 4 mL/kg per h associated with
• Rising serum sodium ≥ 145 mmol/L and/or
• Rising serum osmolarity ≥ 300 mosM and/or
• Decreasing urine osmolarity ≤ 200 mosM
Therapy (to be titrated to urine output ≤ 3 mL/kg per h):
• Intravenous vasopressin infusion at ≤ 2.4 U/h and/or
• Intermittent DDAVP, 1–4 µg IV then 1–2 µg IV every 6 h (there is no true upper limit for dose; should be titrated to
desired urine output rate)
Combined Defined as:
hormonal • Tetraiodothyronine (T4) : 20 µg IV bolus followed by 10 µg/h IV infusion (or 100 µg IV bolus followed by 50 µg IV every
therapy 12h)
• Vasopressin: 1 U IV bolus followed by 2.4 U/h IV infusion
• Methylprednisolone: 15 mg/kg (≤ 1 g) IV every 24 h
Indications:
• 2-dimensional echocardiographic ejection fraction ≤ 40% or
• Hemodynamic instability (includes shock, unresponsive to restoration of normovolemia and requiring vasoactive
support [dopamine > 10 µg/minute or any vasopressor agent])
• Consideration should be given to its use in all donors
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Expert speakers: Expert speakers provided detailed presentations that were instrumental in the development of the recommendations in
this report. They are listed in the order in which they appeared on the agenda.
Dr. Mary Bennett, Resident Training Director, Pediatric Critical Care, British Columbia, Children’s Hospital, University of British Columbia,
Vancouver, BC, and Canadian Critical Care Society; Dr. David Creery, Director, Pediatric Intensive Care Unit, Children’s Hospital of Eastern,
Ontario, University of Ottawa, Ottawa, Ont., and Canadian Critical Care Society; Dr. Anne Dipchand, Clinical Head, Heart Transplant
Program, The Hospital for Sick Children, University of Toronto, Toronto, Ont., and Canadian Society of Transplantation; Dr. Catherine
Farrell, Pediatric Intensivist, Chair, Organ Donation Committee, Division of Pediatric, Intensive Care, Hôpital Sainte-Justine, Université de
Montréal, Montréal, Que.,and Canadian Critical Care Society; Dr. Diane Hébert, Clinical Director, Pediatric Multi-organ Transplant Program,
Hospital for, Sick Children, University of Toronto, Toronto, Ont., and Canadian Society of Transplantation; Ms. Karen Hornby, Critical Care
Nurse and Research Coordinator, Pediatric Intensive Care Unit, Montreal Children’s Hospital, McGill University Health Centre, Montréal,
Que., and Canadian Association of Critical Care Nurses; Dr. Michel Lallier, Surgical Director, Transplantation, Hôpital Sainte-Justine,
University of Montreal, Montréal, Que., and Canadian Society of Transplantation; Dr. Sam D. Shemie, Division of Pediatric Critical Care,
Montreal Children’s Hospital, McGill, University Health Centre, Montréal, Que., and Honorary staff, Department of Critical Care Medicine,
Hospital for Sick Children, University of Toronto, Toronto, Ont., and Canadian Council for Donation and Transplantation, and Canadian
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